Table Of ContentDiagnostic performance of 64-row coronary CT angiography in detecting
significant stenosis as compared with conventional invasive coronary angiography
Amirreza Sajjadieh(1), Ali Hekmatnia(2), Maryam Keivani(3),
Abdollah Asoodeh(4), Masoud Pourmoghaddas(5), Hamid Sanei(6)
Original Article
Abstract
BACKGROUND: The aim of the present study is to evaluate the accuracy of 64-multidetector-row
computed tomography angiography (CTA) in comparison to conventional invasive angiography
(CIA) in the diagnosis of significant stenosis (≥ 50%) of coronary artery tree.
METHODS: Assessment of CTA in the detection of coronary artery disease (CAD) was performed
in patients referred because of symptoms or stress studies suggestive of ischemia. For this
purpose, among more than 1000 cases of coronary CTA in a 20 months period a study
population of 54 patients suspected to have significant stenosis of the coronary artery tree was
investigated. The CIA procedure was performed in these patients one month after CTA. The
accuracy of CTA in detecting significant stenosis was compared to CIA.
RESULTS: For vessel based analysis of 179 coronary vessels, CTA had a sensitivity of 96%,
specificity of 87.5%, positive predictive value of 90.5%, and negative predictive value of 94.6%.
For patient-base analysis, the sensitivity, specificity, positive predictive value (PPV), and
negative predictive value (NPV) of CTA were 97.9%, 28.6%, 66.6%, and 90.2%, respectively.
CONCLUSION: The findings of this study reveal that CT angiography with 64-slice scanner could
be considered as a suitable technique for rapid triage of patients presenting to hospitals with chest
pain. High values of sensitivity and PPV reveal the good performance of CTA in detecting CAD.
Keywords: Coronary Artery Disease (CAD), Computed Tomography Angiography (CTA),
Conventional Invasive Angiography (CIA)
Date of submission: 11 Sep 2012, Date of acceptance: 30 Jan 2013
Introduction the risk of complications, i.e. arrhythmia, myocardial
Coronary artery disease (CAD) is one of the main infarction, stroke, access site problems, etc. Finally,
causes of disability and death all over the world. For nearly one third of CIAs were reported to be
several decades, conventional invasive angiography normal, and therefore this invasive procedure is not
(CIA) has been considered as the well-established necessary for all patients.1 Furthermore, there are
gold standard for making the diagnosis of CAD. constraints on the number of CIA that can be
Conventional invasive angiography (CIA) is highly undertaken, in terms of the cardiologist’s time.2
reliable compared to other indirect evaluation Therefore, an accurate non-invasive alternative
methods such as stress testing. CIA has a high evaluation method for diagnosing CAD is highly
diagnostic ability to determine the extent, location, desirable. Note that noninvasive modalities, like stress
and severity of coronary obstructive lesions. Thus, echocardiography and myocardial radionucleotide scan,
this method remains the main standard for the are unable to evaluate the coronary artery since these
diagnosis of CADs. However, CIA is not a good methods evaluate only the corresponding
choice in some cases due to its invasive nature and myocardial segment. In order to overcome
1- Interventional Cardiologist, Cardiac Rehabilitation Research Center, Isfahan Cardiovascular Research Institute, Isfahan University of
Medical Sciences, Isfahan, Iran
2- Associate Professor, Department of Radiology, Isfahan University of Medical Sciences, Isfahan, Iran
3- Resident, Shahrekord University of Medical Sciences, Shahrekord, Iran
4- Resident, Cardiac Rehabilitation Research Center, Isfahan Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
5- Professor, Isfahan Cardiovascular Research Center, Isfahan Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
6- Associate Professor, Isfahan Cardiovascular Research Center, Isfahan Cardiovascular Research Institute, Isfahan University of Medical
Sciences, Isfahan, Iran
Correspondence to: Ali Hekmatnia, Email: [email protected]
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Diagnostic performance of 64-row coronary
thecomplications of CIA, multi-slice computed of Al Zahra Hospital between March 2010 and
tomography angiography (CTA) has been proposed January 2012.
in recent years as an alternative procedure for In this study 54 patients asked to participate.
determining the presence of coronary obstructions. According to the cardiologist all these patients
With the recent development in hardware with underwent CIA one month after CTA was
multiple detectors, the spatial and temporal performed. Exclusion criteria for CTA were based
resolutions of images have been significantly on technical factors that made the patient unsuitable
improved and consequently CTA has become the for the procedure. These included known allergic
center of interest for clinicians. The reaction to iodinated contrast agents, high baseline
4-slice, 16-slice, and 64-slice imaging machines have heart rate (> 70 beats/min) with contraindication to
been utilized in 1998, 2001, and 2004, respectively.2 beta-blockade, atrial fibrillation, inability to hold the
These machines facilitated the rapid identification breath for 15-s, inability to lie flat, abnormal renal
and assessment of atherosclerosis within the function (serum creatinine level > 1.5 mg/dL). The
moving coronary arteries and potentially reduced detailed characteristics of the study population are
the necessity for CIA. Abdulla et al. evaluated the listed in table 1. The study was approved by the
diagnostic accuracy of 64-slice CTA compared with local ethical review board.
the standard reference CAD.3 Based on their
systematic search, 27 studies including 1740 patients Table 1. Patient demographics and clinical indications
were considered for meta-analyses. Their review (n = 54)
paper validated CTA as a potential alternative to Number Percentage
CIA in patients suspected of having coronary
Male 34 63
stenosis. Mowatt et al. undertook another
Mean age (years) 59 -
comprehensive systematic review and meta-analysis
of the clinical effectiveness and cost-effectiveness of Diabetes mellitus 13 24
64-slice or higher CTA as an alternative to CIA for
Hypertension 22 41
detecting CAD. The diagnostic accuracy and
Smoking 15 28
prognostic studies enrolled over 2500 and 1700
people, respectively.4 Other systematic reviews have Hyperlipidemia 21 39
also been conducted on evaluation of 64-Slice CTA
in the diagnosis and assessment of coronary artery Preparation procedure
disease.2,5,6 Stein et al. preformed a systematic The patients’ heart rates were assessed 1 hour
review on 64-slice CTA for diagnosis of CAD.7 before scanning. Patients with a prescan heart rate
They concluded that negative CTA reliably excluded of higher than 60 beats/min received 50–100 mg
significant CAD. However, the data suggest that oral metoprolol 1 hour before CTA. In the case of
stenoses shown on CTA need confirmation. patients with anxiety, 0.5 mg alprazolam was given.
Combining the results of 64-slice CTA with a If the heart rate was still higher than 60 beats/min
pretest clinical probability assessment would at the time of the examination, intravenous
strengthen the diagnosis.7 Further useful findings propranolol (< 10 mg) was used to achieve a target
can be found in other works that have examined the prescan heart rate of less than 60 beats/min.
accuracy of CTA in comparison with CIA for Sublingual nitrates were used before the procedure.
detecting CADs.8-20 The current investigation was Scanning Protocol
conducted using a 64-row-detector CT scanner to All patients were scanned with a 64-slice single-
evaluate the sensitivity, specificity, negative source CT scanner (Medical health care GE Work
predictive value, and positive predictive value of Station RDW 4.3, GE, USA). The scanning
CTA in identifying significant stenosis (≥ 50%). parameters applied have been reported in table 2.
The accuracy of 64-row CTA is compared with that After calcium scanning, a bolus of 80-100 ml
of the CIA method as the gold standard. nonionic iodinated contrast medium (Ultravist-300)
followed by 50–60 ml of normal saline was injected
Materials and Methods through an antecubital vein by way of an 18-gauge
Patients catheter using a dual injector at a flow rate of 4–6
The study population was chosen from the 1000 ml/s. A dose of 15 ml contrast material was used
patients who were suspected of having coronary during the bolus timing scan calculated (by the
artery disease and who referred to the Heart Center apparatus software) at the level of the descending
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Sajjadieh, et al.
aorta. Seven seconds were added to the calculated CIA findings.
time to carry out the CT procedure. All data sets Statistical Analysis
acquired were reconstructed from the axial, coronal, The CTA accuracy for detecting vessel stenosis was
and sagittal images using a retrospective evaluated by four indicative statistical parameters
electrocardiogram gating with the GE Advantage including sensitivity, specificity, positive predictive
Windows Workstation 4.3. The data set was value (PPV), and negative predictive value (NPV).
reconstructed at 75% of R-R intervals. In cases that These parameters were calculated for vessels and for
motion artifacts resulted in low image quality, the patients and presented as percentages [95%
additional data sets were reconstructed between confidence interval]. The sensitivity parameter shows
25% and 85% of R-R interval to obtain optimal that there is positive CTA among patients with
image quality. positive CIA. The sensitivity is mathematically
Table 2. Angiographic Scan Parameters determined as the sum of true positive divided by the
Number of Slices per rotation 64 × 1 sum of diseased. The specificity parameter implies
the negative CTA among patients with negative CIA.
Individual detector width 0.625 mm
The specificity is calculated as the sum of true
Rotation time 0.33 sec
negative divided by the sum of non diseased.
Tube voltage 120 kVp
Tube current 320 mA Results
Patient-Based Analysis
CTA Image Evaluation The characteristics of the 54 patients were analyzed
The reconstructed images were visually evaluated and the results are presented in table 3. The
for estimation of coronary artery narrowing. Axial obtained results reveal that 2 patients were
images, postprocessing volume-rendered 3D diagnosed as normal by both CIA and CTA (true
images, the maximum intensity projections, negative). Only 1 patient was considered as normal
multiplanar reconstructions, and linear based on CTA findings, but this patient was
conformation of the vessels were used to evaluate diagnosed as abnormal by CIA. This reveals that 1
vessel stenosis. A significant lesion was defined as case was reported as false negative. Figure 1 depicts
more than 50% reduction in lumen diameter. The the typical example of false negative cases where
judgment about the absence/presence of CAD CTA reveals normal coronary arteries but CIA
was made after viewing the various images and shows obstructive CAD. Of the remaining 51
checking stenosis of main coronary vessels, i.e. subjects diagnosed as abnormal on CTA, 46 were
left main artery, left anterior descending, confirmed by CIA (true positive). Figure 2 depicts a
circumflex artery, first diagonal, second diagonal, typical example of true positive cases where both
obtuse marginal, right coronary artery and the CTA and CIA reveal CAD. Finally, 5 cases were
posterior descending artery. reported abnormal on CTA while proved to be
CIA procedure and analysis normal by CIA (false positive).
Routine CIA procedure was performed via the Vessel-Based Analysis
femoral or radial artery. All evaluated vessels were The obtained results of the vessel-based analysis
classified as normal vessels, having non-significant have been reported in table 4. For this analysis 179
disease (luminal irregularities resulting in narrowing vessels were evaluated using both CTA and CIA
< 50%), or as having significant stenosis (luminal procedures. According to the vessel-based obtained
narrowing ≥ 50%). Accordingly, patients were data presented in table 4, 95 true positive, 70 true
classified as positive for the presence of significant negative, 10 false positive, and 4 false negative cases
CAD if there was a significant stenosis in any artery. were reported in this study when compared to CIA
Comparisons were then made between CTA and procedure.
Table 3. Diagnostic performance of CTA for the detection of > 50% stenosis for patient-based analysis
Analysis N TP TN FP FN Sensitivity % Specificity % PPV % NPV %
Patient-based 54 46 2 5 1 97.9 28.6 90.2 66.6
TP: True positive; TN: True negative; FP: False positive; FN: False negative; PPV: positive predictive value; NPV: negative predictive value
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Diagnostic performance of 64-row coronary
Table 4. Diagnostic performance of CTA for the detection of > 50% stenosis for vessel-based analysis
Analysis N TP TN FP FN Sensitivity % Specificity % PPV NPV
Vessel-based 179 95 70 10 4 96 87.5 90.5 94.6
TP: True positive; TN: True negative; FP: False positive; FN: False negative; PPV: positive predictive value; NPV: negative predictive value
b a
Figure 1. A typical example of false negative cases where (a) computed tomography angiography (CTA) reveals no significant
stenosis while (b) conventional invasive angiography (CIA) shows a significant stenosis at proximal part of right coronary artery
b a
Figure 2. A typical example of true positive cases where both computed tomography angiography (CTA) (a) and conventional
invasive angiography (CIA) (b) show a significant stenosis
Discussion CT scanners accelerated this evolution. CTA is
Many progresses have been accomplished to recommended as useful especially for patients with
provide time-saving accurate diagnostic protocols higher complications of CIA. However, a crucial
for CAD suspected patients. The advent of 64-slice issue is to understand how close the CTA and CIA
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Sajjadieh, et al.
findings are. According to the patient-based data Previous research on different generation of multi-
presented in table 3, CTA has a sensitivity of 97.9%, detector CT machines (4-slice, 16-slice, and 64-slice
a specificity of 28.6%, a positive predictive value of scanners) revealed that increase in number of slice
90.2%, and a negative predictive value of 66.6% per rotation results in more accurate results.21 This
when compared to CIA procedure. Furthermore, a trend is expected to be continued for the
sensitivity of 96%, a specificity of 87.5%, a positive forthcoming multisection scanners with higher
predictive value of 90.5%, and a negative predictive number of detectors. For example, new generated
value of 94.6% is reported for vessel-based analysis. 320-row scanners improved image acquisition as
Comparison between the obtained results and those well as reduced radiation dose compared with
presented in other review papers show that both retrospectively gated 64-row CTA.15 Moreover, in
patient-based and vessel-based sensitivity of the recent years, several modified techniques, i.e. dose
present study are very close to the values reported modulation, eliminating helical oversampling,
by previous researchers for 64-slice CTA.5,6 The prospectively gated approach with
high sensitivity of CTA reveals the reliability of this electrocardiogram triggering, and etc., have been
method as a conservative approach for ruling out developed to decrease CTA radiation dose.22-24
CAD via a negative CTA result. Note that due to These technological advances show that the
the high sensitivity of CTA it is very improbable to reliability of CTA can reach that of CIA in the
miss any positive case via this method. A similar future. Furthermore, a systematic heart rate control
trend is observed for the PPV parameter. might significantly improve the diagnostic accuracy
Comparing the present study with other of the present single-source CTA. Note that a
investigations reveals that the computed PPV comparison between single-source and dual-source
(90.2% for patient-based and 90.5% for vessel- CTA revealed the significant influence of heart rate
based analysis) is close to those reported in previous control on enhancing the diagnostic accuracy of
literature.5,6 This reveals the good performance of single-source 192 CTA.8
CTA in detecting CAD, and one can conclude that Limitations
a positive CTA result indicates a significant CAD. In It should be remarked that the present study was
this study, the low values of patient-based specificity preformed based on single-center data, hence the
and NPV might be attributed to the conservative obtained results might not be generalized. The
selection of the study population. Note that CTA following limitations to the present study should be
was conducted on patients suspected to have a considered. First, patients were exposed to a higher
significant CAD instead of randomly selected dose of radiation in CTA procedure in comparison
patients. This conservative approach results in a with CIA.12 Therefore, concerns should be raised
selection bias and the consequent reduction of the about applying conservative radiation dose, and
real negative cases, specificity. However, this careful patient selection especially in the cases of
difference is not observed in the case of vessel-based young people and women of childbearing age.25
analysis in which the computed parameters are close Moreover, note that CTA was conducted on patients
to those reported in previous literature.5,9,18,19 suspected to have a significant CAD referred for
Interestingly, most (70%) false reports, i.e. false CIA. This, results in a selection bias in the study.
positive and false negative cases, are reported for left Therefore, the present diagnostic performance may
anterior descending (LAD) artery. This finding is in not be directly applicable to patients with a lower
accordance with the findings of Sheikh et al., who prevalence of CAD. Finally, it should be noted that
reported lower sensitivity for LAD vessel in heavy coronary calcification and the consequent
comparison with those of other main vascular tree beam hardening are the major limitations to reliable
vessels (RCA and Cx artery).9 Moreover, CTA can evaluation of all coronary arteries.26-28 In these cases
reliably detect patients who need revascularization CIA might be more useful than CTA in obtain
(interventionally or surgically) based on the involved completely reliable diagnoses. It should be noted that
vessels and segments. This is important from the while a calcium score of higher than 600 is known as
clinical point of view.11 a limiting parameter for CTA, this was not a
Technological advancements dominant limitation in present study. Some technical
It is expected that the new generation of scanning tricks like higher flow rates of contrast injection,
machines with higher number of slice per rotation lower heart rates, and reconstruction with sharper
(rows) and higher temporal resolution can diminish kernels and wider window level improved the image
the inaccuracies of the present 64-slice CT scanners. quality.29
ARYA Atheroscler 2013; Volume 9, Issue 2 161
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Diagnostic performance of 64-row coronary
Future directions 2. Mowatt G, Cook JA, Hillis GS, Walker S, Fraser C,
For increasing the diagnostic performance of CTA, Jia X, et al. 64-Slice computed tomography
one might evaluate the myocardial perfusion. This angiography in the diagnosis and assessment of
can be preformed by combining the anatomic data coronary artery disease: systematic review and
meta-analysis. Heart 2008; 94(11): 1386-93.
with physiologic significance of the atherosclerotic
3. Abdulla J, Abildstrom SZ, Gotzsche O, Christensen
lesions. Further investigation is required to develop
E, Kober L, Torp-Pedersen C. 64-multislice
appropriate acquisition protocols for optimal image
detector computed tomography coronary
acquisition and decreased radiation dose. With the
angiography as potential alternative to conventional
developments in CTA technology, future studies
coronary angiography: a systematic review and
should be conducted on reducing radiation
meta-analysis. Eur Heart J 2007; 28(24): 3042-50.
exposure, while maintaining high image quality. 4. Mowatt G, Cummins E, Waugh N, Walker S, Cook
J, Jia X, et al. Systematic review of the clinical
Conclusion
effectiveness and cost-effectiveness of 64-slice or
The present study may have applied clinical higher computed tomography angiography as an
implications for the detection of stenosis of higher alternative to invasive coronary angiography in the
than 50%. Results demonstrated moderately good investigation of coronary artery disease. Health
Technol Assess 2008; 12(17): iii-143.
diagnostic accuracy for the assessment of obstructive
5. Sun Z, Lin C, Davidson R, Dong C, Liao Y.
CAD using 64-row CTA. For vessel based analysis,
Diagnostic value of 64-slice CT angiography in
CTA had the sensitivity, specificity, positive predictive
coronary artery disease: a systematic review. Eur J
value, and NPV of 96%, 87.5%, 90.5%, and 94.6%,
Radiol 2008; 67(1): 78-84.
respectively. For patient-based analysis, these values
6. Paech DC, Weston AR. A systematic review of the
were 97.9%, 28.6%, 66.6%, and 90.2%, respectively.
clinical effectiveness of 64-slice or higher
The high value of sensitivity reveals the good computed tomography angiography as an
performance of CTA in ruling -out CAD. Similarly, it alternative to invasive coronary angiography in the
has been reported that high PPV indicates the investigation of suspected coronary artery disease.
reliability of CTA in diagnosing CAD. While the mean BMC Cardiovasc Disord 2011; 11: 32.
specificity and NPV of patient-based analysis is lower 7. Stein PD, Yaekoub AY, Matta F, Sostman HD. 64-
than those reported in previous literature, this slice CT for diagnosis of coronary artery disease: a
difference is not observed in vessel-based analysis. The systematic review. Am J Med 2008; 121(8): 715-25.
8. Achenbach S, Ropers U, Kuettner A, Anders K,
findings reveal that CT angiography with 64-slice
Pflederer T, Komatsu S, et al. Randomized
scanner could be considered as a suitable technique for
comparison of 64-slice single- and dual-source
rapid triage of patients presenting to hospital with
computed tomography coronary angiography for
chest pains. It should be noted that further
the detection of coronary artery disease. JACC
investigation is required to determine whether 64-row
Cardiovasc Imaging 2008; 1(2): 177-86.
scanning technology has sufficient resolution to
9. Sheikh M, Ben-Nakhi A, Shukkur AM, Sinan T,
delineate CAD. Al-Rashdan I. Accuracy of 64-multidetector-row
computed tomography in the diagnosis of coronary
Acknowledgements artery disease. Med Princ Pract 2009; 18(4): 323-8.
10. Carrascosa P, Capunay C, Deviggiano A, Goldsmit
The technical support of the multi-slice CT ward of
A, Tajer C, Bettinotti M, et al. Accuracy of low-
Alzahra Hospital and the angiography ward of Sina
dose prospectively gated axial coronary CT
Hospital are acknowledged. Furthermore, the
angiography for the assessment of coronary artery
financial support of the Isfahan University of
stenosis in patients with stable heart rate. J
Medical Science is gratefully acknowledged.
Cardiovasc Comput Tomogr 2010; 4(3): 197-205.
11. Miller JM, Rochitte CE, Dewey M, Arbab-Zadeh
Conflict of Interests A, Niinuma H, Gottlieb I, et al. Diagnostic
Authors have no conflict of interests. performance of coronary angiography by 64-row
CT. N Engl J Med 2008; 359(22): 2324-36.
12. Coles DR, Smail MA, Negus IS, Wilde P, Oberhoff
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Criteria Task Force, the Society of Cardiovascular
Computed Tomography, the American College of
Radiology, the American Heart Association, the
How to cite this article: Sajjadieh A, Hekmatnia
American Society of Echocardiography, the
A, Keivani M, Asoodeh A, Pourmoghaddas M, Sanei
American Society of Nuclear Cardiology, the North
H. Diagnostic performance of 64-row coronary CT
American Society for Cardiovascular Imaging, the
angiography in detecting significant stenosis as
Society for Cardiovascular Angiography and
compared with conventional invasive coronary
Interventions, and the Society for Cardiovascular
angiography. ARYA Atheroscler 2013; 9(2): 157-63.
Magnetic Resonance. Circulation 2010; 122(21):
e525-e555.
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